Quality Surgical Care and Outcomes for Patients With Non–Small-Cell Lung Cancer
Authors: Kenneth L. Kehl, Michael T. Jaklitsch
Journal: Journal of Clinical Oncology (2023)

The curative potential of surgical resection for non-small-cell lung cancer (NSCLC) was established nearly a century ago, with pneumonectomy initially constituting the primary operative approach. 1As surgical techniques became more refined, 2 lobectomy when feasible became the standard of care 3 and less invasive techniques including video-assisted thoracic surgery 4 and robotic-assisted thoracoscopic surgery have reduced surgical morbidity. 5Despite the evolving role of systemic therapy in the treatment of early-stage NSCLC, now including cytotoxic chemotherapy, 6 targeted therapy, 7 and immunotherapy, 8,9 surgical resection still plays a critical role in curative treatment.Extensive evidence indicates that the quality of surgery plays a key role in clinical outcomes for early-stage NSCLC.Lung cancer resections by more specialized surgeons have been associated with better outcomes. 10,11Specialization is also associated with improved process measures, including rates of lymph node sampling 12 and preoperative staging, 11 which has, in turn, been associated with better survival in high-risk patients. 13However, rates of adherence to guideline-recommended surgical process metrics have been suboptimal. 14Quality improvement efforts, such as a lymph node dissection kit, have demonstrated the ability to improve both surgical care processes and outcomes. 15,16Still, associations between individual surgeon performance on quality metrics and outcomes and the potential for care process improvement to mitigate surgical outcomes have not been well-characterized.In the article that accompanies this editorial, Ray et al 17 analyzed the association between surgical quality and patient survival after resection for NSCLC using data derived from lung cancer resections occurring in the Mid-South Quality of Surgical Resection cohort from 2009 to 2021, which was also the subject of their earlier lymph node dissection kit process improvement study. 15,16Using data before kit implementation, surgical quality tiers were defined on the basis of rates of margin-positive resections, wedge resections, resection without lymph node examination, and resection without mediastinal nodal evaluation.Separate tiers were constructed for each metric.Resections after kit implementation were then categorized into these predefined tiers for each metric and aggregate.Among these postimplementation resections, associations were then measured between surgeon tier and patient survival, first using unadjusted models and then after adjustment for patient characteristics and different surgical quality processes (Fig 1).The authors found that several surgical quality metrics, including nonexamination of mediastinal nodes and wedge resection rates, improved between the pre-and postimplementation periods.As expected, patients of surgeons in the highest-quality tier per the study's definition were more likely to have invasive mediastinal staging, to meet National Comprehensive Cancer Network criteria for surgical quality, to undergo robotically assisted procedures, and to have R0 resections.Patients of surgeons in lower-quality tiers had higher mortality rates than patients of surgeons in the highest tier.These mortality rate differences were mitigated after additional adjustment for other surgical quality processes (indicated in the manuscript as model hazard ratio 3 ), including preoperative positron emission tomography-computed tomography, preoperative invasive staging, surgical technique, and lymph node dissection kit use.This may imply that mortality differences by surgeon could be mitigated by optimizing such processes.This study also examined quality metrics among wedge resections, which is particularly relevant in light of JCOG0802/WJOG4607L and CALGB/Alliance 140503, which compared sublobar resection with lobectomy for patients undergoing surgery for peripheral stage IA ACCOMPANYING CONTENT